Surgical treatment modalities for complicated aneurysms and pseudoaneurysms of arteriovenous fistulas

Purpose: This study was designed to determine the clinical presentation, characteristics, and management of aneurysm/pseudoaneurysm formation (APF) in dialysis access fistulas. Methods: The treatment methods and outcomes of 31 patients who underwent surgery for APF in dialysis access fistulas were retrospectively reviewed over a 9-year period. Results: We performed 1558 operations for arteriovenous fistulas (AVFs) between 2000 and 2009 at our centre. Of the 1558 operations, 35 were carried out for APFs (2.2%) on 31 patients. Thirty of these operations were restorative. Twenty-two (71%) of these patients had their original access done elsewhere, and all corrective surgeries were performed at our hospital. Approximately 52% of the subjects were female, with a mean age of 45.7 +/- 17 years. The mean duration of end-stage renal disease was 70.2 +/- 51.5 months. The mean number of AVFs per patient was 2.2 +/- 1.5. Synthetic grafts were used in five patients (16.1%). Most of the procedures were left-sided (67.7%) and brachial-cephalic fistulas (48.3%). Among 31 complications, 22 were arterial/venous aneurysms (71%) and nine were pseudoaneurysms (29%). Fourteen patients (46.6%) were treated by excision of the aneurysm and primary suture repair. The post-intervention primary patencies for all revised APFs were 68%, 56%, and 52% at 1, 6, and 12 months, respectively. Dysfunction of AVF (16.1%) and bleeding (12.9%) were the most encountered complications after aneurysmectomy. Conclusion: Reformative operations should be considered in cases of urgency and irresponsiveness to endovascular surgery rather than closing the fistulas directly, as it prolongs the duration of AVF patency.